Title: Fasting Plasma Glucose in Non-Diabetic Participants and the Risk for Incident Cardiovascular Events, Diabetes, and Mortality: Results From WOSCOPS 15-Year Follow-Up
Topic: Prevention/Vascular
Date Posted: 4/21/2010
Author(s): Preiss D, Welsh P, Murray HM, et al.
Citation: Eur Heart J 2010 Apr 15. [Epub ahead of print].
Clinical Trial: No
Related Resources
Trial: The West of Scotland Coronary Prevention Study (WOSCOPS)
Study Question: Is a fasting plasma glucose (FPG) in the nondiabetic range a risk factor for long-term risk of cardiovascular disease (CVD)?
Methods: A total of 6,447 men with hypercholesterolemia (4.5-6 mmol/L) participating in the West of Scotland Coronary Prevention Study (WOSCOPS) who had a FPG but no history of CVD or diabetes (FPG <7.0 mmol/L), were followed for CV events and mortality over 14.7 years of follow-up. Patients were randomized to pravastatin 40 mg daily or placebo and followed initially for an average of 4.9 years. The primary outcome of the follow-up extension study is the relationship between FPG and CVD defined as a composite of fatal and nonfatal CVD events including coronary heart disease (CHD), stroke, and CHD deaths. Comparison of time to first event was determined by Cox proportional hazards models with Q2 as referent because of the J-shaped relationship between FPG and CVD mortality (18 mg/dl glucose = 1 mmol/L glucose).
Results: Mean age was 55 years; 2,381 nonfatal/fatal CV events and 1,244 deaths occurred. Participants were divided into fifths of baseline FPG, Q1 (≤4.3 mmol/L) to Q5 (>5.1-6.9 mmol/L). Compared with Q2 (>4.3-4.6 mmol/L), men in Q5 had no elevated risk for CV events (hazard ratio [HR], 0.95 [0.83-1.08]), or all-cause mortality (HR, 0.96) in fully adjusted analyses despite a significant risk for incident diabetes (HR, 22.05 [10.75-45.22]). After further dividing Q5 into fifths, Q5a-e, individuals in Q5e (FPG 5.8-6.9 mmol/L) were also not at increased risk of CV events or other endpoints compared with Q2. All results were similar using Q1 as the referent.
Conclusions: Elevations in FPG in the nondiabetic range were not associated with long-term risk of CV events in middle-aged men in WOSCOPS. These data suggest that the current FPG cutoff for diagnosing diabetes also appropriately identifies western men at risk of CVD.
Perspective: That an elevated fasting glucose predicts the development of diabetes over 5 years, but not CV events over the following 10 years in WOSCOPS is a surprise, considering the findings in other populations. In stark conflict is the recent report from the Atherosclerotic Risk in Communities Study (Selvin E, et al. N Engl J Med 2010;362:800-11) in which a glycated hemoglobin >5.5% is associated with an increase in risk for diabetes and coronary disease independent of other variables, and the relative risk for each 0.5% increment in glycated hemoglobin is considerable. Melvyn Rubenfire, M.D., F.A.C.C.
Title: Implantable Cardiac Device Procedures in Older Patients: Use and In-Hospital Outcomes
Topic: Heart Failure/Transplant
Date Posted: 4/21/2010
Author(s): Swindle JP, Rich MW, McCann P, Burroughs TE, Hauptman PJ.
Citation: Arch Intern Med 2010;170:631-637.
Clinical Trial: No
Study Question: What are the age-specific practices and outcomes among patients with heart failure undergoing implantable cardioverter defibrillator (ICD) implantation?
Methods: The cohort included patients older than 18 years with a diagnosis of heart failure who underwent implantation of an ICD or cardiac resynchronization therapy (CRT) between January 1, 2004, and December 31, 2005. Data included patient demographics, comorbidities, type of device, procedural complications, length of stay, total cost of hospitalization, and hospital characteristics. Multivariate stepwise logistic regression analysis was used to identify risk factors for in-hospital mortality. Age groups were chosen to directly evaluate mortality risk among patients 80 years or older relative to younger patients, as this cohort was excluded from randomized clinical trials or was markedly under-represented.
Results: The authors identified 26,887 patients who received an implantable device. The median age was 70.0 years (17.5% were ≥80 years), 72.6% were male, and 31.3% were of nonwhite race/ethnicity. Compared with younger patients, those 80 years or older were more likely to receive CRT alone. In-hospital mortality increased from 0.7% among patients younger than 80 years to 1.2% among those ages 80-85 years and 2.2% among those older than 85 years (p < 0.001). Independent predictors of in-hospital mortality included age 80 years or older, elevated comorbidity score, inotrope use, and procedure-related complications.
Conclusions: The authors concluded that advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in older patients.
Perspective: The investigators found that despite the fact that most device trials have excluded patients 80 years or older, more than one-fifth of ICD and CRT devices are implanted in this age group. Furthermore, procedure-related complication rates and in-hospital mortality are elevated in patients with advanced age. It seems that additional studies are required to clarify the appropriateness of device implantation in older patients with heart failure, as well as the merits of less invasive options and/or medical therapies. For the present, physicians need to individualize therapy based on the medical issues and patient wishes, and meaningfully discuss the potential risks and benefits of the procedure with each patient. Debabrata Mukherjee, M.D., F.A.C.C.